A 35 year-old Chinese male with a known history of Crohn’s disease was diagnosed in 2014 and treated with nine doses of infliximab. He had normalization of his colon on follow up colonoscopy, but without complete resolution of the patient’s symptoms. He was started on azathioprine and his symptoms worsened. Repeat colonoscopy showed recurrence of Crohn’s disease. He was restarted on infliximab in January 2016 and the patient received four doses. Follow up colonoscopy shows improvement in colonic mucosa, but he had persistence of abdominal symptoms. He also noticed blurring of vision in the left eye which was getting progressively worse. Over a month period, he noticed some visual disturbances in the right eye as well. Therefore, he saw an ophthalmologist who diagnosed a 4 cm choroid mass in the left eye with loss of vision and a normal right eye. Infliximab was discontinued and anti-tubercular treatment with four drug regimen was started. After two months of antitubercular therapy, he had clinical improvement with resolution of presenting abdominal symptoms, and decrease in size of the left eye choroid mass and stabilization of vision. The patient came to us for a second opinion regarding Crohn’s disease vs intestinal tuberculosis. We performed CT scans that showed multiple subcentimeter lesions in liver, spleen, lung, kidney, 4.5 cm mass on pole of left kidney and many subcentimeter lesion in both kidney, hilar and mediastinal lymphadenopathy, diffuse colitis.
Discussion:
Here we present a case of miliary tuberculosis presenting as a choroid mass after infliximab treatment.
This case highlights that–although screening for TB with a skin PPD and a chest X-ray should be performed in all patients–this is not 100% effective and may be a problem in patients on concomitant immunosuppression. Therefore, high risk patients should be counseled regarding TB prophylaxis.
The clinical course of this patient further shows that in a patient treated with infliximab, whose clinical condition does not improve, one should always be suspicious of the possibility of an alternative diagnosis, like GI tuberculosis in this patient. Even though tuberculosis is usually not rapidly fatal, the disease may show a fulminant course in immunocompromised patients.
Conclusions:
Hospitalist should be aware of unusual presentations of miliary TB and eye threatening adverse events related to a commonly prescribed very effective therapy for Crohn’s disease.